Fighting for Good Health

While it seems that doctors are making buckets of money, lawyers have found a way to change this in concert with the political movers and shakers who are following suit. Many veteran physicians are encouraging young students to stay away from medicine for fear of endless paperwork, insurance battles and lawsuits. The face of medicine is changing.

Medicine Is A Business

What once used to be a profession geared towards healing the disabled and sick has now become a battle for safeguarding ones career. Often referred to as "CYA" (cover your a__) medicine, doctors are ordering more tests so not to miss pathology and treating minor ailments in vain. They put forth great efforts to serve their patients, but must protect their practice from suing patients, money-hunting lawyers and non-paying insurers. Some discussion with physicians about the subject often brings up ideas for reform with what sounds like logical plans to solve the issues at hand. In some markets doctors are paid almost 50% for their services as a result of under-insured patients or insurers who just won't foot the bill claiming there were non-qualified expenses. Since when can people utilize a service provider, demand services and pay nothing? When I go to the supermarket looking for home goods, they are certainly going to laugh when I ask them to put it on my tab.

In some places the "fee-for-service" model has done well. Patients want their health care provided and pay the provider an agreed upon fee. Both parties are satisfied and treatment is given. There is talk of requiring all citizens to have health insurance. I am still trying to understand why this would be a bad thing. I choose to drive a car; I get insured. I choose to receive health care; I get insured. Seems simple. Research has shown that people value things more when they have to "pay" a nominal fee for it. Even if there was a required co-pay, at least it would show sincerity of the purchaser to the provider that they have a significant concern needing to be addressed. It becomes taxing on the medical systems to provide free or discounted care more often than not. Perhaps that is why one third of hospital emergency departments have closed across the country in the last few years. Uncompensated services cannot last forever.

Whether paying in cash, through an insurer, Medicaid or Medicare, it seems fair to be offering remuneration to physicians for their hard work rather than trying to scheme ways to leave them empty handed. While each insurance organization has various offerings to their clients, some may come up incomplete, requiring users to seek for additive options. Medigap insurance plans for example, offer to fill in the gaps that Medicare Part A and B do not cover. It brings peace of mind to patients that experience a wider coverage of care and allows providers to give comprehensive services.

As I move into medical practice it is hard to know what medicine will be in the future. Policies are being written into law and health care reform is happening at the national level. Medicine as it is known today may be inside out and backwards years from now. Hopefully, parties on both sides of the fence find will be able to latch onto something positive so the face of medicine is tainted no more than it already has been.

Question of the Week

What are the issues, past and present including the proposed efforts of health care reform?

Answer & Explanation

Medical Coding

Guest post from Deanne Hicks, Medical Billing and Coding Instructor

Greetings! My name is Deanne Hicks and I have worked in the Health Information Technology field as a certified coder for the past ten years. So, what is coding? The greatest analogy I can use to describe coding is to compare it to learning a new language. Essentially, it is the art of storytelling. A coder abstracts information from the patient's medical chart and translates that medical information into alpha or numeric codes that are up to five characters in length. There are several uses for codes, with the most common usage to drive reimbursement for providers. The other uses are for statistic collection, vital records for cause of death, public safety for communicable disease reporting, epidemic/pandemic reporting from hospital records in certain geographic areas and a host of other topics.

You may wonder how someone becomes a coder. For me, I needed a life change and decided to go back to school. Having just gone through a fairly difficult pregnancy, undergoing several encounters with a myriad of different providers over a course of almost two years, medical terminology and anatomy became fascinating to me. I wanted to learn more! I signed up for a diploma program as a medical office assistant and away I went, on a journey from which I have never turned back. I learned more about the human anatomy than I ever thought possible. When I took my medical terminology course, I was completely hooked! Once I got to the medical billing and coding portion of my program, I was on cloud nine. Although medical billing an insurance didn't interest me, I still persevered onward, patiently awaiting this thing called medical coding. Once I learned how to code, it was as if I had found my passion. For the first time in my life I knew what I wanted to be when I grew up...a Coder.

Earlier, I mentioned that coding is first and foremost, utilized in order to get the provider paid. As young medical students who dream of becoming a physician someday, wouldn't you eventually like to get paid for your time? I realize you will most likely have a hefty student loan to repay, so I suspect you will appreciate getting maximum reimbursement for services rendered. Yes, your practice will have a coder to assist you in this effort, but what you need to keep in mind is this; coders code from the medical record so the more complete and specific the documentation is, the more specific the code choice will be. In turn, the higher the reimbursement might be!

Here is a great example, hypertension. In the coding manual, hypertension is divided into three types, those being malignant hypertension, benign hypertension and unspecified hypertension. Malignant hypertension (ICD-9 code 401.0) is defined as very high blood pressure that comes on suddenly and quickly, with the diastolic reading above 130mmHg. With malignant hypertension, complications could arise with kidneys, blindness or an increased risk of stroke or myocardial infarction. If a patient exhibits symptoms such as blurred vision, confusion, anxiety, chest pain, nausea, vomiting, shortness of breath, or weakness in the limbs with a high diastolic reading, malignant hypertension needs to be considered. However, more often than not, the treating physician will simply enter the abbreviation of "HTN" on the encounter form. Because coders code from the medical documentation given, the only code choice would be unspecified hypertension (ICD-9 code 401.9). Also, benign hypertension's (ICD-9 code 401.1) definition describes this type of hypertension as slightly elevated blood pressure which, if left untreated, could cause cardiovascular and central nervous system complications.

If a physician were to document and diagnose the specific type of hypertension, this would open up the opportunity to allow a deeper evaluation of the patient with blood work, ECG if warranted, additional body systems to examine and evaluate as well. In order to code the encounter in the outpatient setting, the more body systems examined and the more test results to review on subsequent visits, the higher the level of coding for the physician's cognitive skills. All things considered, the reimbursement level for the provider will increase over a period of time, which will certainly help to make the practice thrive and in turn give the patient a higher level of care.

Everyone is a winner! Here is the successful chain of events:

1. Medical students learn to give greater detail in medical documentation in preparation for future billing
2. Coders and billers can code more specifically from detailed documentation
3. Greater reimbursement can be obtained
4. Patient's, doctors and coders are happy

So, physicians-in-training, add one more thing to your to-do list. Take a coding course offered at your local community college. Arm yourself with coding knowledge. I realize your brains are constantly being stuffed like a turkey with all that medical info, but as you know, we only use a small portion of brain power anyways. Cramming a little more knowledge into that head of yours will pay off for you big time!

Good luck!

Deanne works with Lincoln Group of Schools, a group of career training schools. She is a medical billing and coding training instructor, which is one of the various Lincoln programs available.

Question of the Week

While attending the cardiology clinic, the staff nurse measures the blood pressure of a 61 year-old man and finds that it is 182/100 mmHg sitting and 190/104 standing. He has a heart rate of 82/minute, with an irregularly irregular rhythm. On auscultation of the heart, there are no murmurs, but he has bibasilar crackles on chest examination. Which of the following pathological findings is most likely to be present?

A. Left ventricular hypertrophy
B. Left atrial myxoma
C. Occlusive coronary atherosclerosis
D. Cor pulmonale
E. Mitral regurgitation

Answer & Explanation

Medical Investing

With a little work directed appropriately our efforts will pay off in the end. It is a matter of making the initial investment that determines the success we obtain. As Benjamin Franklin said, "An investment in knowledge pays the best interest."

Seeking Dividends

There are definitely times when it becomes difficult as a student to see the finish line. We question everything we are doing and wonder if it makes any sense at all. Think just for a second, how many people do you know would pay thousands of dollars to work for free, be given endless hours of study responsibility, and be deprived of leisure or sleep for four years? I thought it was funny when my attending recently commented that nobody pays to go to work and that it just wouldn't make sense for people to invest like that. In good humor I rose my hand and said that I do, to which he quickly replied that my situation was different. I disagree, however. My time, money and resources are currently being invested in my education so that one day I can realize a lifelong goal and reap the accrued interest.

Unfortunately, we are not educated in school as to the inner workings of medical business. Most of that must be learned in practice or from personal research. As far as finances go, there are some wise decisions to be made, assuming you know what those are. One of my favorite places to get money-wise information for the medical professional is at PoorMD. From one who has been there and done that, the author gives great financial advice that is easy to implement at any stage of practice. It's just a matter of seeing now the potential our investments could have latter, and taking advantage of those opportunities.

Question of the Week

A 4-month-old male presents with twitching of the facial muscles. He has previously been seen for several severe episodes of Candida infections. On examination, the child has low-set ears, hypertelorism, and a shortened philtrum. What additional findings would be likely in this individual?

A. Prominent telangiectasias around the eyes
B. Decreased alpha-fetoprotein
C. Decreased IgA levels
D. Elevated IgM levels
E. Absent thymic shadow on chest x-ray

Answer & Explanation

Student Loan Debt

The start of our last block sure feels good. Soon enough we will be seeing patients and interacting with physicians in the community, unfortunately that comes with a price.

Student Loan Repayment Options

Just as we are preparing to file our FAFSA for the next year we received the bad news that there will be a 5% tuition increase! Apparently this figure is low, but it still adds up. The AMA reports that the majority of medical students have more than $100,000 of debt. Ask a student and after performing the math they will tell you that their debt is closer to $200,000 or more. We have no idea how the health care reform will affect future medicine and the financial concerns it carries. From my understanding, it is difficult to be a physician and not be bothered by the monetary repercussions of business. In fact, many practicing doctors are still paying off student loans.

A growing concern is the dwindling number of family practice physicians. For many students the pay alone is a deterrent that promotes interest in medical specialties. Fortunately, there are some specialties that are eligible for loan repayment opportunities. Here are a couple resources worth investigating if you are looking to get that student loan monkey off your back and you are not interested in the military scholarship:

• National Health Service Corps - Family Medicine, Obstetrics/Gynecology, General Internal Medicine, Gerontology, General Pediatrics, General Psychiatry
• AAMC - Loan repayment/forgiveness and scholarship opportunities by state

Board Prep Question of the Week

A 6-year-old child is brought by ambulance to the emergency room following an automobile accident. She is covered with blood and unconscious secondary to hemorrhagic shock. Her parents urge the physician to do everything possible, but implore that no blood products be used to treat their daughter. What is the best course of action for the physician to take?

A. Administer blood without delay and contact child protective services
B. Convene an urgent meeting of the hospital ethics board
C. Engage the parents in a discussion of why they hold these beliefs
D. Transfuse blood as needed, explaining the situation to the parents
E. Treat the patient without using blood products, per the request of her parents

Answer & Explanation 

Federal Student

Although I never really imagined having time to be employed anywhere as a medical student, I was happily surprised when the opportunity presented itself. This is the cadaver lab where we dissected cadavers and where I participate in the federal work-study program.

Federal Student Work

No longer a run-of-the-mill student, but a federally paid student, I reduce some of the hefty student loan I borrowed and learn at the same time. Nationally, students at more than 3,000 institutions are hired part-time to help in various operations and other positions. Almost two-thirds of the pay comes from federal funds geared towards students in financial need...for which most medical students qualify. The remaining third comes from the institution and all remuneration is tax free.

Once first year ended, I gained employment as a laboratory assistant in the bioskills and anatomy labs at Touro University-Nevada. Currently, the labs are home to 47 cadavers, the majority of which coworkers and I are preparing for the incoming DO class of 2013. Some are being prosected in preparation for allied health students within TUN's other colleges. I must admit that my job is probably one of the more unique federal student positions available.

In addition to earning a little extra among the cadavers, I will be able to brush up on anatomical landmarks and terms. This should bolster some of the already fading memories of structures once learned. Although impossible to work off my student loans in this position, if it helps when boards come around, I will be one step closer to graduating as a doctor. When that happens, no more federal student for me, instead my tax dollars will be feeding into the next generation of federally paid student employees.

Clinical Corner

Willed Body Program

The cadavers that are provided for students are obtained via willed body programs. A number of these programs exist around the country which are often associated with medical universities. An individual can specify that they would like their bodies to be used for the purpose of medical research by filing a donor form before dying. This gift to science has benefited the medical community in ways that the common public is not aware. In the university setting, these individuals are often considered a student's first patient.

Discount Medical Books

It's time again to purchase the next series of textbooks and supplies. Those that cannot be found at Google Books may just have to be purchased at a reasonable price elsewhere.

Book Discounts

Fortunately, some professors reuse texts from the first year cutting down on book costs significantly. If this is not the case, here are a few learned ideas that may come in handy:

• Upperclassmen are often willing to sell used school books which would cut out the problem and expense of shipping and handling
• The school library will usually have course texts available for loan at no expense to you
• Deal Oz - Scouring more than 200 online stores, they find the best prices on the net, coupons and discounts apply to both new and used products...use it
  

Selling Used Books

If you are like most medical students, you are always looking for a little spending money, even if that means you just need to make up the difference in the cost for discounted books. It might be time for you to sell used textbooks. Honestly, most of them you will never use again and others will be outdated in no time. Rid your shelves of those that are taking up space while people still want them.

Despite the large variety of small textbook businesses, it may be wise to stick with the more common vendors; half, ebay, and amazon. If you would rather see your used textbooks go to good use, consider the incoming class, they will be looking for your great offers.

Tax Time

Just when things start to mellow out, I can feel Uncle Sam reaching deep into my already emptied pockets. It's that time of year again when W-2 forms show up in the mailbox, numbers get crunched, and taxes get paid.

Tax

Considering all the things that taxes are used for I guess they aren't too terrible, but they certainly don't help my situation financially as a student in plenty of debt. Once all the government documents arrive and get filed we get to file even more as students.

It wouldn't be possible to pay for school without a little help from the government. Therefore, completing the FAFSA and other scholarship opportunities permits my education to continue. Considering some of the tax breaks, the process a little more bearable (thank you new house). I certainly don't mind being able to file taxes for free.

Expenses

As the numbers become quite important, I thought a running total of expenses for Touro University Nevada's College of Osteopathic Medicine would be appropriate.

• Tuition - Roughly $37,000
  
• Books - $1000.45 (Used and new)
  
• Equipment - $1,550.65 (Laptop, lab coat and diagnostic tools)
  
• Clubs - $40
  
• Extra - $202.29 (Software, vaccines, etc)

Obviously these will vary from year to year and student to student, but it is in the right ballpark. Moving, housing and food expenses have not been included. With Valentine's Day around the corner, you can help curb some of these costs and get some fantastic deals, consider some of these great gift ideas.

Clinical Corner

Epistaxis (Nose bleed)

Research says that about 90% of nose bleeds occur as a result of damage to Kiesselbach's area. It is found in the front part of the nose and has a rich blood supply. The predominant reoccurring trauma is caused by fingers that are doing too much scratching. A smaller percentage comes from the back of the nose that cannot be reached by fingers which often requires medical help. Stopping a nose bleed may take time, and is good knowledge to have if you ever need it.

Rationed Time

The long days that never seem to end are certainly anticipated experiences. Only in the beginning of the whole process, I am learning to ration my time to the many tasks that demand my attention.

New Home

We finally closed on our new home and moved in last week (hence the missed post). It took our mortgage broker a long time to finalize the transactions and was more than a headache with a new problem or delay every day. Being first time home buyers has been quite the hassle and I know many medical students wrestle with the decision to become home buyers or simply rent.

In making our decision we had learned that renting a unit in Las Vegas would cost nearly the same as a mortgage. Our struggle was mostly with the mortgage lenders being flexible once we found the house we wanted. We waited until the very last minute before making the deal official.

All I can say is that if you are entertaining the thought of home buying, start well before matriculating. We ended up staying with family for almost a month. It was great to spend time with them, and we will forever be grateful for their hospitality. We just hate to have out-stayed our welcome. Renting sure sounded tempting on occasion, but our new home was worth the effort.

Student Loan

Reimbursement for the expenses of medical school cannot come too soon. With all the costs of living increasing and becoming more abundant, staying financially afloat is a rather fancy dance. I can come up with a lengthy list of debts, but if you are reading this you could name them just as well.

My financial institution is finally funding my tuition and reimbursement checks. It is a huge relief to know we will be able to buy groceries next month and have a roof over our heads. Visit the past post for more student loan info.

Exams

I knew medical school would move quick, but I had no idea we would cover an entire book in less than a couple months. Midterms were only one month in and next week will be our first week of exams. "Block week" as they call it, occurs three times a semester, testing our memory and endurance skills. With 24 credits this semester, I should start having nightmares any night now.

Somehow I managed to make it through my first couple tests despite the late...late nights of studying. This method is not recommended for two reasons: 1)Taking a test while fatigued makes information recall ineffective and 2)It's bad for your physical health. Of course I would like to have performed better, but the information was spilling out of my head by the time I took the test. I think I need to reformat my cerebral hard drive and free up a little space.

Student Organizations

I have been blown away and slightly annoyed by all the organizations vying for my money. Who knew there were so many student medical associations? Each one asks for membership money but none really have a significant impact that seems evident. The benefits they have expressed usually include free meals, discount suture clinics, and the ever popular screen printed tee-shirt.

I may be new to this medical school thing, but I'm not an idiot. My intention is to pass and earn a degree. If that means I cannot join an organization my first week of school, please support me in that decision. Perhaps down the road I will share a portion of my student loan with you so I can say I belong to your club. Maybe in the meantime you could come up with better reasons than a free lunch to be a member of your organization.

Discount Books

I am growing what seems to be a never ending stack of books. A couple of months ago, Touro sent me a list of 'Required' and 'Recommended' text books for First Year students. At last, the time for real-deal medical books has come...or so I thought.

Buying Medical School Books

After receiving some feedback from veteran students and practicing physicians, I saved hundreds of dollars. Actually it was rather intuitive; do NOT purchase the 'Recommended' books. They certainly may contain some useful information, but I think I will have plenty to read within the covers of my 'Required' library that superfluous texts will only add to my lack of time.

With that decision made, the list was cut in half, leaving me a little less in debt. The remaining 20 books, however, are starting to make my shoulders ache just thinking about carrying them to class.

Since I have not yet received my loan reimbursement, the new problem is being able to pay for $2500 worth in books. My solution has worked thus far and costs approximately $250 every pay check. I made an initial order and waited for the shipment to arrive before selecting the next handful of texts to purchase. It is exciting to think I am one order away from having all my books and the projected total is a little more than $1000.

Bargain Prices

Some students opt to borrow or share texts with their neighbors. Good idea, but I plan to spend some serious time with my books. TUNCOM has an online bookstore that gives back to the school when used to purchase texts as many schools probably have. This is great for the school, unfortunately there is very little discount to the student.

There is an option for getting the books for free, since that includes the military, that option is out for me. As most students are doing now, I turned to the internet's vast library of cheap books. Although there are many online stores for purchasing text books, the two with the greatest savings are no surprise. Between ebay's half.com and omnipresent Amazon, there is a lot of saving power.

The part I like is that you are helping other people sell their books. I imagine down the road I will have to sell mine too, so it is a way to build up positive karma I suppose. Perhaps you are more into funding a 'better' cause. In that case you may be interested in purchasing books for full price and then some at Better World Books who make an effort to stamp out illiteracy.

If used books are viable options, prices can be significantly reduced. Other considerations may be older editions, borrowing, and buying the books as soon as possible. I learned this the hard way. When I first performed my book search, the prices were almost one third of the original. Now only weeks away, costs are up as the cheaper selections have already been bought by others.

Between the Book Covers

As I searched the confines of Amazon, I came across the 'wish list' feature. When you find something you like, you simply click the wish list button to add it and others can see what you want. My list became an organizational tool for me, but if you have a gift giving event coming up, you may consider sharing your wish list with others. Who knows, perhaps they will be able to help cut down on the costs for books and supplies.

With work and preparations to move, opening these books has not been the first thing on my list of priorities. They certainly look attractive though. Knowing I will have plenty of time to digest the material, I am enjoying my vacation now while I am still ahead. For now the mystery will maintain my intrigue.

Student Loan

There are a few ways to pay for that expensive medical school education. Unless you have a great inheritance, win the lottery, or find a sac of hidden cash, it is likely that student loans are the only way to pay. I never found the pot of gold at the end of a rainbow and now must look for other financial options.

Scholarships and Grants
If you have the grades, the time, and the will power, it is wise to search for a little free money. Grants and academic scholarships helped fund a large portion of my undergraduate studies leaving me debt free upon graduation.

The hardest part is sitting down and looking for matches that meet your personal qualifications. FastWeb is a great place to start as it does the sorting for you. With the right grant or scholarships, the medical school expenses can be significantly buffered.

Student Loans
Once scholarship opportunities are exhausted, the most common method for payment comes from borrowed money in the form of a loan. With rising costs for medical school, loans are becoming more substantial all the time. Loans to consider: Stafford, Grad PLUS, Perkins, and private.

Stafford Loans
Stafford loans come in two forms, unsubsidized and subsidized. $32,000 and $8,500 can be borrowed from these loans respectively, totaling $40,500. This will satisfy tuition, but not easily the other expenses of room, board and supplies. Interest is paid by the US department of Education for subsidized loans while in school where unsubsidized loans require the interest to be paid by the student from the time of disbursement. Obviously subsidized loans are preferred in this regard. Interest rates may be high, but some lenders offer benefits to curb the overall expense.

Grad PLUS Loan
These loans are backed by the government and come with a fixed interest rate of 8.5%. As these are usually supplementing the Stafford loans, they are not need based and vary according to the amount of aid already received. You cannot borrow more than the cost of attendance. A good credit history will make this loan easy to obtain.

Perkins Loan
The Perkins loan is a federally funded loan that provides aid to those who are exceptionally needy. It offers a low interest rate to those who qualify.

Private Loans
Should the loans above not provide adequate funding, private loans are available to supplement your resources. Do not over-borrow as it will one day have to be repaid. Interest rates are not fixed and other requirements may apply.

Lenders
Finding the right lender can be difficult. Compare the terms of service and special offerings before selecting your lender. Some will offer all or a couple of the loans listed above. Use one lender for all your loans. Once the time comes to repay your loans, the process of loan consolidation will be made easier offering a lower interest rate.

I chose to use MedInvest as they offered greater discounts than the other lenders I researched. With on-time payments and direct withdrawal, similar sized loans save almost $2,000-3,000 over the lifetime of the loan.

Application
I have chosen to apply for the Stafford loans and some Grad PLUS loan money. TUNCOM has a loan application form that is filed once a lender is chosen. The financial aid office applies for Stafford loans on my behalf. In order to obtain Grad PLUS money, I must apply with my lender of choice for the amount of desired money on my own. Since my wife will be able to work during my time in school, it is not requisite that I borrow the full amount available. Since I would like to buffer some of the expenses, I will obtain a small Grad PLUS loan to help cover living expenses.

In every case, it is necessary to fill out a FAFSA application as this is how lenders approve your loan request. Never incurring debt until this point in my life has been a great accomplishment. Now that I must borrow money to thrive, the natural fear that is associated with owing something to someone else is very daunting.

One physician I spoke with said that students are poor and doctors are rich. Borrow a little extra during school in order to live moderately so that the transition is not too drastic. Good advice, I hope that is still the case when I graduate.

Late Nights and Long Shifts

The day this picture was taken at 3 in the morning, the local trauma room was quiet. It certainly doesn't take much for it to become the most active place in the hospital in a matter of minutes. Just this past week, this room alone was used to stabilize, save and improve the life of dozens of individuals. The occasional and emotional loss of life occurs inevitably, but you had better believe the room is usually in shambles as a result of all the effort put forth to overcome another expiration.

I love my job. As an Emergency Department Technician we may do a lot of the so called "dirty" work, but it has its perks. Watching people get better usually ranks among the better ones. If we aren't doing CPR, starting intravenous (IV) access, drawing blood, collecting urine or stool samples, then we are probably transporting patients to radiology, their longterm rooms, monitoring their vital signs or preparing for the next ambulance to arrive. Usually working long 12 hour shifts, the work-week commonly only requires three shifts, translating to four days off.

With an understanding that medical school will be quite expensive simply for the education itself - not to mention housing, car and other expenses - paying off any existing debt now will certainly help down the road. I commonly pick up extra shifts to help buffer the onslaught of bills and rising prices in all markets. Being at the bottom of the totem poll though, means that I work the graveyard shifts quite frequently in addition to some of the other unwanted shifts. Not always the most pleasant of circumstances, but at least it pays to have the experience in preparation for long hours as a physician.

There is something great to be said about working hard and earning money for your own efforts. I've always enjoyed working and earning, but I have always had a hard time spending. Usually looking for ways to save or invest my income, I find it difficult to incur so much debt at this point in my life. As a rule of thumb, I make it a point to invest 10% and save 30% of my net earnings, leaving 60% to go towards bills and other expenses. Now I know this will likely have to be modified as the income stops and the payments start, but in the meantime I have the plan to keep me on track. For some other tips and ideas, you might want to head over to the Poor MD blog.

Financial Woes Before Matriculation

With a letter of acceptance in my hands and only two weeks from the date of its arrival, I had to decide whether Touro was the school for me. One week passed and the deadline continued to approach ever so quickly. I faxed my letter of intent to the office of admissions; confirming my decision to attend TUCOM in the fall.

If only it was that simple. Just when I thought I was done, in order to show them proof of my desire to attend, I had to make a sort of down payment, that would "reserve" my seat. That wouldn't have been so bad if it were pocket change; it cost $2000. Lucky for me I had enough in my savings account to meet the demand and still eat my peanut butter and jelly sandwich for lunch! Can you see me smiling? You know the big cheesy grin that says, 'I can't believe I just spent so much money and to think this is only a fraction of the cost.' At least this goes towards my tuition.

A couple days later, still eating PB&J for lunch and loving every moment of it, I received more letters of felicitation emailed to my inbox. They were well received until I realized it was time to get back to work. My "To Do" list just quadrupled in size... literally. I had just paid $2000 to find out it was time to spend more money.

1. New this year, Touro is requiring all first year students to have a laptop. So if you own one, that's not really a problem. Unfortunately, I don't fall into that category. Now I'm on the hunt for a new way to spend another $2K, this time in the form of a mechanical box that is smarter than me. I am considering a tablet PC as it may offer functions more suitable to the classroom. (I could just write my notes on slides rather than type my own set in an outline) The appeal of a regular laptop is that I already know the major functions and could work efficiently from the start.
   
2. All students are required to have medical insurance. This isn't really something new, just that it means I have to look for insurance again as I will be leaving my current employer. They mentioned that there is an allotment of $2000 which I assume can be included in the cost of my loan to cover this expense. That is unless my wife has a job that comes with the proper benefits.
   
3. Speaking of loans, in my mind this translates to debt. The school pointed me in the direction of an online loan counseling session. It is a program that defines the main points of loans, important definitions and some of the consequences if I fail to repay the borrowed money.
   
• Certainly, the first place to start is with the FAFSA once your taxes are finished.
• Next, look for independent scholarships to help reduce overall costs at FastWeb.
• Specific to Touro and many other institutions is the online loan counseling.
• It is recommended that you verify your credit report FREE for any inconsistencies.
4. Before matriculation, I have to prove my health in the form of a physical. An immunization and medical history, if I can gather all that paperwork, is needed too.
5. Perhaps only requested by Touro, one more copy of my undergraduate transcript showing that I really did attend college and meet the prerequisite requirements.

They informed me that I was placed on the mailing list for my graduating class of 2012. That should be really nice for study groups and other activities, should we ever have the time for a BBQ or something. After a little searching, I found my class had a group on Facebook and a forum at the Student Doctor Network. It's good to know I have a way to contact other students before even attending the school.

Now that I've officially declared my future full of debt, it's time to look at housing. To buy or not to buy... condo, townhouse, single family home. What lender is going to want me -- pretty soon I won't even own half of the assets I use!